Page 103 - Area X - D

• Are you related by consanguinity or affinity to the appointing or recommending authority, or to the
chief of bureau Or office or to the person wh/~^' immediate supervision over you in (he-Office,
4^ i
Bureau or Department whereyou will be app^^.ued, ; >
a.within the third degree?• • ' ' ly] , , • ; '' • ; |
O'YES I 0 NO
b.within foe fourth degree (for Local Governm^nt Unit-Carebr'Emplpype^)? „. ; ..„,,, , , . ? iVES-r - D NO-
If YES, give details:

35 a Have youever been found guilty of any administrative offense?
D YES0 NO
If YES, give details:

b, Have you been criminally charged before any court? 0 YES0 NO
If YES, give details:
Date Filed:
Status of Casefs:
36 Have you ever been convicted of any crime or Violationof any taw, decree, ordinance or regulation
D yes0 no
by any court or tribunal?,
If YES, give details:
37 Have you ever been separated from the service'in any of the following modes: resignation, 0 YES0 NO
,' retirement, dropped'from the rolls, dismissa^ termination, end of term, finished contract or phased If YES, give details:
out (abolition) in the public or private sector?
:.' a. Have you ever been a candidate in a national or local election held within the last year (except
0 yes 0 no
e,Barangayeleclion)?SYvi;•,,,;;,,:,,:• -,,, . ' ;, •
If YES, give details:
b. Have you resigned from the government service during the three (3)dnorith period before the last O YES 0 no
election to promote/actively campaign for a national or local candidate?
If YES, give details:
-39. Haveyouacquirea-thOstatusofonlmmlgrantorpermarentresidentofanotherCountry?
0 yes0 no
If YES, give details (country):
:*o. 'Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carte for Disabled Persons (RA
.,: ,7277); and(c) Solo Parents Welfare Act of 2000 (RA8972). please answer the following items:
Are you a*metnberof;any,indigenous,group?,, ,,
0 yesO noD no
If YES, please specify:TU WALI
'<>• Are you<flrperpion;wifhMdisal)iiit^? •;,,
0 YES0 NO
If YES, please specify ID No:
*• Areybuesoloparent?
0 YES0 NO
If YES, olease soecifv IB No:
'1 • REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)
NAME
LEONORE D. BULAYO, RETIRED TEACHER KIANGAN, IFUGAO
NORMA D. BULAHAO TEACHER, HUCAB

I declare udder Oath that I have personally accomplished this Personal Data Sheet which is a true, cored and
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the
Philippines, I authorize toe agency head/authorized representative to verify/validate the contents stated herein.
I agree that any misrepresentation made in this document and its attachments shall cause the filing of
administrative/criminal case/s againstme.

Government Issued ID itaPfssp^. gsis sss, pro, Duvar-i ttcwie, etc.)
PLEASE INDICATE /pNumher and Pate of Issuance
Government Issued 10:
IDIUcense/PasspoitNo.:
Signature (SQn inside lire box)
MARCH 20, 2018
Date/Piece of Iseuance: 2015, IFSU, NAYON
SUBSCRIBED AND SWORN to before me this libiting his/her validly issued government ID as indicated above.

Person Administering Oath
CS FORM 2 f? (Reused r